Provider Demographics
NPI:1992253009
Name:MILLER, SHAWN LAURITZ SR (OWNER)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:LAURITZ
Last Name:MILLER
Suffix:SR
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3069 CISCO CT
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-1809
Mailing Address - Country:US
Mailing Address - Phone:805-624-7700
Mailing Address - Fax:
Practice Address - Street 1:3069 CISCO CT
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-1809
Practice Address - Country:US
Practice Address - Phone:805-624-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-18
Last Update Date:2016-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA560051AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility